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- 1. Diverticulitis Luke Ong: OMS III, ATSU-SOMA
- 2. Learning Objectives • To understand clinical presentation of diverticular disease and complications. • To describe imaging findings suspicious for diverticular disease. • To determine management options for diverticular disease. • To determine indications for operation in diverticular disease • To understand operative approaches and benefits, drawbacks • To identify the steps needed to assess a patient after surgery and what symptoms to look for to ensure a safe recovery.
- 3. A 66 yo male comes into the ED d/t worsening abd pain. Over the past week, he has had vague lower abdominal discomfort, nausea, anorexia, and constipation. This morning, the patient had sudden, severe lower abdominal pain accompanied by an episode of vomiting. The pain initially improved but then gradually intensified to involve the entire abdomen. On physical exam the patient is alert, uncomfortable, heart/lung normal. Diminished BS. Abd diffusely tender w guarding and rebound tenderness. T 38.3 C (100.9 F), BP 110/54, HR 108 RR 20 Abdominal imaging is most likely to reveal which of the findings? • a) colonic dilation w loss of haustral markings • b) dilated small bowel w a transition point • c) embolic occlusion of a mesenteric artery • d) free air in the peritoneal cavity
- 4. 65 yo f to the ED w 2 day hx of lower abd pain, nausea w/o vomiting. Pmh osteoarthritis and constipation (docusate). T 37.9 C (100.2 F), BP 144/92, HR 90. LLQ tender to deep palp. CT shows sigmoid diverticula and perisigmoid stranding suggestive of inflammation. The patient is started on oral cipro and metronidazole and sent home. Three days later she returns to the ED with persistent abd pain, nausea, fever. Last BM 12 hr ago. PE shows LLQ wo guarding/rebound. CT shows 5 cm rim enhancing perisigmoid fluid collection. Next step? a) IV ab and observation b) Laparotomy for colonic resection c) Laparotomy for drainage and debridement d) Oral ab, bowel rest, observation e) Percutaneous abscess drainage under CT guidance
- 5. Anatomy
- 7. Presentation/Risk factors • Fever • LLQ pain • Leukocytosis • • Vitals/WBC • PE • Additional Imaging? • Labs • ddx
- 8. Labs • CBC • Wbc • Hg/Hct • BMP • Coagulation studies • PT/INR • PTT • B-hcg • LFT? Amylase/Lipase? UA?
- 11. Steps • Mobilization of the descending colon along the white line of Toldt • Mobilization of the splenic flexure • Allows for tension-free anastomosis in the pelvis • Anastomoses under tension have increased leak rates • Division of the distal descending colon and rectosigmoid junction • Ligation of the sigmoid mesentery • Unlike in a cancer operation, the mesentery may be taken close to the bowel wall, as opposed to at the root. This is because lymph node resection is not required. • Once the specimen is removed, a hand- sewn or stapled anastomosis is performed. • A leak test is performed by insufflating air per rectum while submerging the anastomosis under water and looking for bubbles. • No bubbles = no leak • If bubbles are noted, the surgeon may re- do the anastomosis and try again. Alternatively, depending on the condition of the colon and other factors, the surgeon may elect to perform a proximal diversion with a loop ileostomy to allow the anastomosis to heal. • Finally, the abdomen is closed in the usual fashion
- 12. Post op • Check bowel function • Advancement of diet • infections • After 8 weeks?
- 13. Our Patient – not so easy • TV is a 83 yo m w recent hx of surgery early Dec for pyloric ulcer perf • 1/13 presents to ED w abd pain, diarrhea for 2 weeks, 20lb weight loss, and fevers at night. • Abd tender to palp, lactate/procalcitonin elevated, white count elevated, anion gap • CT showed “persistent pneumoperitoneum near stomach from 12/6” • 1/14 ICU on vasopressin + norepi. Ex lap -> sigmoid colectomy w creation of descending colostomy (Hartmann's procedure). Peritonitis 2/2 perf sigmoid diverticulitis • 1/16 extubated, off pressors. Bradycardia 40’s, +dopamine • 1/17 wbc trending down, lactate normal, anion gap resolved • 1/19 V fib + LOC Today he is doing pretty well! Eating and learning how to use ostomy.
- 14. Thanks! Questions? References • https://wise-md.med.nyu.edu/v3/wmd/#/module/overview • https://www.reliasmedia.com/articles/135320-diverticulitis- evaluation-and-management • http://www.stritch.luc.edu/lumen/MedEd/Radio/curriculum/Surgery /diveriticulitis2.htm • https://www.researchgate.net/figure/The-Hinchey-Classification-of- perforated-diverticulitis_fig1_239850464
Editor's Notes
- small mucosal herniations protruding through the smooth muscle in the layers of the bowel wall There are false, or pseudo diverticulae in the sense that they don't contain all layers of the bowel wall, but only the mucosa and submucosal layers. Typically, these false diverticulae are due to a pushing force. true diverticulae, such as the appendix, contain all layers of the bowel wall. , in the US they are more common in the sigmoid. Diverticulosis refers to the simple condition of having diverticula, which may be asymptomatic in the majority of cases. Epidemiology – age <40 yo less than 5% 85+ 65% Risk factors: low fiber diet, constipation, obesity
- Occasionally, fecal material or undigested food becomes lodged in the diverticula obstructing it. this leads to inflammation Diverticulitis, however, means that one or more of the diverticula become inflamed, as indicated in this CT scan by fat stranding and haziness of the bowel wall. CT findings: acute uncomplicated diverticulitis are fat stranding…Bowel thickening or possibly a small pocket of extra luminal air. complicated diverticulitis have more serious issues.
- Is the patient septic? PE: distention? Tympanic? Peritonitic? Img: Xray – pneumoperitoneum – perforated something - free air? dilated loops of bowel -> ileus/obstruction CT findings: acute uncomplicated diverticulitis are fat stranding…Bowel thickening or possibly a small pocket of extra luminal air. complicated diverticulitis have more serious issues. A perforation may be associated with a phlegmon, which is an ill-defined area of inflammation involving the colon or a discrete abscess. So you might see a mass of inflamed tissue near where the diverticulitis is located. You could see a fistula from the colon, most commonly to the bladder, or you might see obstruction that would be demonstrated by dilated loops of small or large intestine proximal to the affected area. Labs?
- In ordering and evaluating laboratory studies in a patient with diverticulitis, you may want to include a CBC with differential looking at the white count for inflammation or signs of infection. The hemoglobin and hematocrit for dehydration and anemia. The BMP includes electrolytes and renal function studies which also give you an indicator of dehydration. Surgery: PT, PTT, and coagulation studies, beta HCG LFT's, amylase and lipase are generally not indicated unless you're ruling out another disease, and you may order a urinalysis for symptoms of a UTI in consideration of a colovesical fistula.
- The management of acute diverticulitis is largely dictated by the stage of the disease at presentation. The modified Hinchey Classification scheme separates acute diverticulitis into a spectrum of severities. Mild clinical diverticulitis (stage 0) and inflammation confined to the pericolic region (stage 1a), meaning otherwise uncomplicated diverticulitis, are typically treated conservatively with bowel rest and IV antibiotics. this is “uncomplicated diverticulitis” The presence of a pericolic abscess or phlegmon (stage 1b) and that of a pelvic, retroperitoneal, or distant intraperitoneal abscess/phlegmon (stage 2) indicate the need for possible drainage in addition to antibiotics. The more severe complicated diverticulitis classifications include the presence of purulent peritonitis in which there is no communication between the bowel lumen and the peritoneal cavity (stage 3) and feculent peritonitis with open communication (stage 4). These patients will need emergent surgery.
- Resected amount: The distal margin must be the proximal rectum identified by the splaying of the teniae The proximal margin does not have to include all of the diverticuli but must include the entire muscular portion of the sigmoid colon. This is where diverticulitis is most likely to occur, and ‘we determine this point by palpating the muscular portion of the sigmoid wall. The diseased sigmoid itself will feel woody and thickened; whereas, the distal descending colon will feel healthy and soft. Hartmanns procedure: resection of the rectosigmioid colon w closure of the anosrectal stump and formation of end colostomy
- >>: Post operative care in patients who have had surgery for diverticulitis include routine issues such as monitoring of bowel function. This is done by assessing for nausea and vomiting as well as the passage of gas and bowel movements. Nasogastric tubes, if they’re used, can be removed early unless the patient has high outputs recorded. Advancement of the patient's diet can be done as tolerated if the patient isn't nauseous or distended, or if they have signs of return of bowel function. Pulmonary toilet and ambulation should be encouraged, and the use of narcotics minimized. Additionally one must monitor for signs of infection as some of the most common complications after bowel surgery are wound infection or intra-abdominal abscesses. Both of these should be suspected if the patient has persistent low-grade fever, nausea and vomiting, or abdominal distention particularly around postoperative day 5 . Long-term complications include recurrent diverticulitis. In patients who have not had a preoperative colonoscopy, such as patients who underwent urgent or emergent surgery, a colonoscopy should be done to assess the remaining colon at four to six weeks postoperatively . Issues such as constipation and potential dietary recommendations should be discussed with the patients as well.